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Reasons for Slow Adoption of Vaccines in the Elderly

Describe about the Clinical Psychology and Gerontology for Vaccination Against Measles.

1. It has been found from the paper of Ozawa et al., (2014) that almost all the children receive vaccination against measles, diphtheria, polio but very few adults attempt for vaccination for protection against pneumococcal and influenza disease despite they have the potential to save or reduce their sufferings. The literature review shows slow adoption of the vaccines in the elderly. SteelFisher et al., (2015) highlighted that in Singapore the schedule of vaccination for adults is not offered comprehensively when compared to other countries such as Australia, Europe, and the United States. Therefore, several studies have been conducted to understand the reasons for slow adoption of vaccines in the elderly.

Ang et al., (2013) believes that the importance of the vaccinations in enhancing the immune system of aging is unknown to many. There is a lack of awareness about the ability to protect against infections even in chronically ill patients. Currently, MOH recommends adult vaccines for people in high-risk groups or severe chronic illness to protect against Influenza and Pneumonia. In spite of the newly set national guidelines very few adults are vaccinated. According to the specialist of infectious disease, Mr. DrLeong Hoe Nam at “Mount Elizabeth Novena Specialist Centre” the slow adoption of vaccines in the elderly is due to lack of awareness among health care providers, patients and their families (Low et al., 2015). Studies conducted by Eng et al., (2014) showed that few proportion of patient are aware of the fact that influenza leads to death in individuals who are already suffering from other diseases such as Diabetes, Asthma, lung disease as well as those with weakened immune system. There is also the lack of awareness that the recent tetanus vaccine, which includes a booster for a whooping cough, renders protection to the adults as well as their grandchildren.

There is varying rate of effectiveness for the adult vaccines unlike children vaccines, which are found to be 100% effective for polio and measles. The shots for pneumonia and flu are not successful which another reason for lagging adult immunization rates. In 2014, the rate of infection by flu reduced by only 19% after receiving flu vaccines in Singapore, which made difficult to persuade the older adults to get vaccinated (Ang et al., 2015). In addition, many physician dot not recommend vaccines more often or incorporate them into routine care and many physicians do not consider vaccinations a priority for adults (Tan et al., 2016). According to Tomczyk et al., (2014) new vaccine pricing owing to its complexity is leading to medical, scientific and public health ramifications. This pricing system has slowed down the adoption of the vaccination, as such vaccines do not reach the market to their full potential. The cost of one influenza jab is $35, and that about pneumococcal vaccine is about $80 in privatized health clinics. The high cost is the biggest hurdle for the care providers and patients.  The shelf life of shingles vaccine is very short which makes its storage difficult in personal offices of physicians and therefore patients themselves has to get it from health clinics or pharmacy. Consequently, this extra step deters patients (Fatha & Goh, 2014). The private insurances cover vaccines in addition to preventive services, but then the same deal is not applicable in the case of Medisave or Medicare where in one part the Flu and pneumonia shots are free, but shingles and tetanus vaccines may be covered in other part or require the copayment. In Singapore, Medisave does not pay for vaccinations (Tan et al., 2016).

Importance of Vaccination Education Programs

There is a need of enhanced effort to strengthen these areas to improve the speed of vaccine adoption among the elderly and prevent life-threatening ailments. The government of Singapore must develop measures and policies for improvement in vaccination programs for adults.

2. Vaccination is the cornerstone to control infectious disease and reduce the rate of mortality and morbidity. Since Singapore is a compact city, it is easy to administer vaccines to the large population quickly with systematic and good monitoring of adverse consequences. Singapore can improve adult vaccination in elderly by various ways, which are discussed in subsequent sections.

Thein et al., (2013) Stated that there is an increase in efforts from the doctor to introduce more vaccines for the adults in Singapore. Currently, MOH recommends adult vaccines for people in high-risk groups or severe chronic illness to protect against Influenza and Pneumonia. Public hospitals should start programs to increase the adult vaccine rates. In addition, Singapore can implement “pre-discharge vaccination” as a standard of care similar to US and Canada (Natarajan & Shankar, 2015). In every hospital, a significant proportion of inpatients suffer from conditions, which demands them to be immunized against chronic diseases. Therefore, offering these vaccines to them before the discharge would be a good opportunity. The patients on the other hand can lump the “cost of vaccination” within the hospital bill. The MOH should ensure the viability of paying for vaccinations using Medisave. It will reduce the cash outlay for the patients. Hospitals must hold "annual vaccination exercise" for the patient who has undergone Kidney transplantation. This has been found to be successful in UK in immunizing 89% of the patients with Kidney disease against pneumococcal, hepatitis and influenza disease (Thein et al., 2013). Since these patients are immunocompromised, such interventions are helpful to reduce long-term complications.

Vaccination education programs should target adult population to create awareness about how aging drops the immunity, the level of risks and complexity associated with infections after the age of 50 years. There is a need to educate about the deadly "lockjaw" condition caused when not immunized against tetanus. That may increase the immunization rates of tetanus (Nguyen et al., 2015). The education programs should target at promoting health changing behavior in elders by enhancing self-efficacy and motivation. It is essential to increase the awareness in elderly about the need to take preventive health steps by updating them about the recommended vaccines and the terrible condition, which can be prevented (Natarajan & Shankar, 2015). Physicians should be instructed to strictly follow the national guidelines that should mandate them to recommend vaccines to all the older patients with weakened immunity. These will increase the awareness and adoption of vaccines by older patients. The MOH in Singapore can implement a “multifaceted quality improvement initiative” in all the health organisations to increase the prescription of the “influenza and pneumococcal vaccines” in elderly and diabetics. Since such methods have shown improvements in some health institutes, it appears to be effective. However, there is a need for measures to evaluate its sustainability and applicability in all the primary care settings as well as safe reporting system (Tomczyk et al., 2014). According to Nguyen et al., (2015) this method in Singapore have increased the influenza vaccination from 9% to 47.1% and Pneumococcal Vaccine from 6% to 47.1% in a 5-month period.

Role of Physicians and Policies for the Vaccination Program

Singapore government can offer “drive-through flu shots” to the patients in their cars, or the Uber service providers can use a cell phone app to allow the customers to get free vaccines (Said et al., 2013). There is need of implementing e-health technology in Singapore owing to it multifunctional benefits. The health systems can identify the seniors who are in urgent need of vaccination through a quick search of electronic health records. Providing telehealth services is more advantageous as it brings care into a home (Bonten et al., 2015). According to Muhammad et al., (2013) the best way to increase the speed of the immunization in elderly is by engaging every staff in health organization right from the front office to back office in vaccinations. This is an effective method, as it does not lay the entire burden only on the physicians.


The policy maker should incorporate training programs for health care professionals to provide intense care to the older patients. It must develop “pilot community-based care services” for older patients. The MOH must implement policy-directed program evaluation and National Seniors framework for improving the vaccination rate (Ang et al., 2013). Further, the insurers, payers, policymakers should make enhanced efforts to improve adult vaccination coverage rates. According to the theory of generativity by Erik Erikson, older people must expand their care beyond oneself (Ozawa et al., 2014). They should pass their wisdom and knowledge towards other in broader societal contexts to promote better health. Therefore, the community programs or service centres in Singapore must implement similar theories and concepts. The stakeholders must be presented with the data of the deaths due to lack of immunization in elderly to promote such programs in hospital and communities. The supporting evidence should be based on randomized control trials and other studies. The stakeholders and the health authority must collaborate internationally to implement vaccination success strategies of other countries such as Canada, US in Singapore (Bonten et al., 2015).

3. “Pneumococcal disease” is third leading cause of death associated with infection in children as well as in adult in Singapore (Thein et al., 2013). In Singapore, there were 380 cases of invasive pneumococcal disease per year during 2000-2008. More than 50% of them were older patients with 21% of fatality rate. However, in the year 2014, the number decreased to 164. Patients above 65 years of age are highly susceptible to this invasive disease. Vaccination is the cornerstone to control infectious disease and reduce the rate of mortality and morbidity. A pneumococcal vaccine has a potential to prevent life-threatening ailments and can prevent the global health problem. However, there is a slow adoption of pneumococcal vaccine in elderly in Singapore (Tan et al., 2016).

Pneumococcal vaccine is vital for the older patient both at individual and at the community level because of deadly complications associated with the infection once developed (Muhammad et al., 2013). The causative organism of this disease is Streptococcus pneumonia, and its pathogenicity is mainly due to capsular polysaccharides. It can be manifested as-

Bacteraemia- characterized with non-specific signs of illness and high fever

Meningitis- presents with a severe headache, fever, stiffness of neck, nausea,vomiting, and pain when exposed to bright light

Innovative Approaches to Increase Immunization Rates

Bacteremic pneumonia- is presented with rapid breathing, chills, cough, fever and chest pain (Said et al., 2013)

There are several complication due to pneumococcal pneumonia such as lung abscess and pericarditis, pneumococcal meningitis leads to significant learning disabilities, paralysis, speech delays and even death (SteelFisher et al., 2015). Lack of pneumococcal immunization may kill a huge number of people owing to the slow adoption of this vaccine. The vaccine is necessary both at individual and community level due to its transition from asymptomatic carriage to invasive form. It is highly infectious and can quickly spread to various parts of the body such as lungs, middle ear, blood, coverings of the brain and spinal cord. It can spread from person to person through direct contact or droplets from an infected person while coughing or sneezing or articles contaminated that with infected droplets (Tomczyk et al., 2014). This implies the safeguard against this deadly disease both at the individual and at a community level. Infection to one person can reach a hundred others and increase the death and disability rate. However, effective intervention can stop the invasive chain of infection. Untreated patients can suffer septic shock, acute respiratory failure, multiorgan failure, and within several days can lead to death after its onset (Ozawa et al., 2014).  

The rationale for highly targeting elderly population (above 65 years) for this intervention is their weakened immunity and fragility. Older people with diabetes, lung disease are highly prone to this disease. The other risk factors in older adults that facilitate the development of the disease include chronic heart disease, alcohol consumption, smoking, and previous hospitalization for pneumonia. Singapore has been reported with increasing elderly population and hence decreasing pneumococcal disease is an important priority. Across the world the incidence of pneumococcal disease increases with age and the mortality is disproportionately high in an older group of population (Natarajan & Shankar, 2015). Also, there is an increase antibiotic resistance among various strains of S. pneumonia, and these are highly found to infect older patients with comorbidities (Fatha et al., 2014).

In conclusion, there is a need for herd immunity to eliminate or minimize the death due to PD. The “Health Sciences Authority (Singapore regulatory body)” has approved the use of “23-valent pneumococcal polysaccharide vaccine (PPSV23)” and “PCV13” for the prevention of PD in adults (Tan et al., 2016). The former is highly effective for patient above 65 years of age and with comorbidities. However, a combination of both is best for high-risk adults.

References

Ang, L. W., Cutter, J., James, L., & Goh, K. T. (2013). Seroepidemiology of hepatitis B virus infection among adults in Singapore: a 12-year review.Vaccine, 32(1), 103-110.

Ang, L. W., James, L., & Goh, K. T. (2015). Prevalence of diphtheria and tetanus antibodies among adults in Singapore: a national serological study to identify most susceptible population groups. Journal of Public Health, fdv011.

Ang, L. W., Tey, S. H., Cutter, J., James, L., & Goh, K. T. (2013). Seroprevalence of hepatitis B virus infection among children and adolescents in Singapore, 2008–2010. Journal of medical virology, 85(4), 583-588.

Bonten, M. J., Huijts, S. M., Bolkenbaas, M., Webber, C., Patterson, S., Gault, S., ... & Patton, M. (2015). Polysaccharide conjugate vaccine against pneumococcal pneumonia in adults. New England Journal of Medicine,372(12), 1114-1125.

Eng, P., Lim, L. H., Loo, C. M., Low, J. A., Tan, C., Tan, E. K., ... & Setia, S. (2014). Role of pneumococcal vaccination in prevention of pneumococcal disease among adults in Singapore. International journal of general medicine,7, 179.

Fatha, N., Ang, L. W., & Goh, K. T. (2014). Changing seroprevalence of varicella zoster virus infection in a tropical city state, Singapore.International Journal of Infectious Diseases, 22, 73-77.

Low, S. L., Lam, S., Wong, W. Y., Teo, D., Ng, L. C., & Tan, L. K. (2015). Dengue seroprevalence of healthy adults in Singapore: serosurvey among blood donors, 2009. The American journal of tropical medicine and hygiene, 14-0671.

Muhammad, R. D., Oza-Frank, R., Zell, E., Link-Gelles, R., Narayan, K. V., Schaffner, W., ... & Harrison, L. H. (2013). Epidemiology of invasive pneumococcal disease among high-risk adults since the introduction of pneumococcal conjugate vaccine for children. Clinical Infectious Diseases,56(5), e59-e67.

Natarajan, V. S., & Shankar, B. H. (2015). Challenges in the Management of Pneumococcal Disease in Older Adults. The Journal of the Association of Physicians of India, 63(4 Suppl), 13-16.

Nguyen, M. H., Chen, L. L., Lim, K. W., Chang, W. T., & Mamun, K. (2015). Vaccination in Older Adults in Singapore: A Summary of Recent Literature.Proceedings of Singapore Healthcare, 24(2), 94-102.

Ozawa, S., Privor-Dumm, L. A., Nanni, A., Durden, E., Maiese, B. A., Nwankwo, C. U., ... & Foley, K. A. (2014). Evidence-to-policy gap on hepatitis A vaccine adoption in 6 countries: Literature vs. policymakers’ beliefs. Vaccine, 32(32), 4089-4096.

Said, M. A., Johnson, H. L., Nonyane, B. A., Deloria-Knoll, M., Katherine, L. O., & AGEDD Adult Pneumococcal Burden Study Team. (2013). Estimating the burden of pneumococcal pneumonia among adults: a systematic review and meta-analysis of diagnostic techniques. PloS one, 8(4), e60273.

SteelFisher, G. K., Blendon, R. J., Kang, M., Ward, J. R., Kahn, E. B., Maddox, K. E., ... & Ben?Porath, E. N. (2015). Adoption of preventive behaviors in response to the 2009 H1N1 influenza pandemic: a multiethnic perspective. Influenza and other respiratory viruses, 9(3), 131-142.

Tan, K., Wijaya, L., Chiew, H. J., Sitoh, Y. Y., Shafi, H., Chen, R., ... & Lim, T. (2016). An outbreak of Group B Streptococcal CNS infection in Singapore: unusual clinical and MRI findings (P1. 330). Neurology, 86(16 Supplement), P1-330.

Thein, T. L., Leo, Y. S., Fisher, D. A., Low, J. G., Oh, H. M., Gan, V. C., ... & Lye, D. C. (2013). Risk factors for fatality among confirmed adult dengue inpatients in Singapore: a matched case-control study. PloS one, 8(11), e81060.

Tomczyk, S., Bennett, N. M., Stoecker, C., Gierke, R., Moore, M. R., Whitney, C. G., ... & Centers for Disease Control and Prevention (CDC). (2014). Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among adults aged≥ 65 years: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep, 63(37), 822-5.

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